Family Physicians versus Nurse Practicioners

How do you feel about the decline in family practice doctors? Do you think nurse practitioners and the like will fully replace family doctors in the future?
 Anonymous

Thank you for your question!

I know many extremely smart, talented, and capable Nurse Practitioners and Physician Assistants working across various specialties.  We are blessed in the health care community and as a population to have them in our ranks as health care professionals.

I don’t believe that mid-level practitioners are the ultimate solution to our ‘physician shortage’.  The real issue with physician shortages is regional (excluding the looming ‘baby boomer’ issue).  If your community is in a very rural and isolated area the problem isn’t that there aren’t enough physicians to cover the region, it is that health care providers, regardless of profession or specialty, tend to want to move to areas that offer more social opportunities, strong schools, and spouse employment opportunities.  If you increase the number of Nurse Practitioners and increase their scope of practice, they are just as likely to not want to practice in these areas as their physician colleagues.  

Regarding Family Medicine in particular, a Family Physician is a specialist in providing care to the individual, the family unit, and the community.  Not including undergraduate pre-medical education and the first two years of medical school, the 3rd and 4th year medical school clinical years and the completion of residency training in Family Medicine encompasses between 20,000 and and 22,000 hours of clinical training to become a Family Doctor.  As you can see from this blog, Family Physicians are trained to work competently in various settings- from continunity outpatient clinics, emergency rooms, and the ICU, from providing obstetrical and maternity care, pediatrics, or working as hospitalists.  A Family Doctor is expected to be able to care for 90% of the problems a patient may present with 90% of the time.  Compare this with between 2800 and 5300 clinical hours for masters-level to doctorate-level Nurse Practitioners.   

Most people don’t know a Family Physician who practices the full scope of clinical Family Medicine, usually because the full-scope of Family Medicine is encountered in the rural or international setting.  This has generally been self-imposed by Family Physicians themselves.  Most people hate getting up in the middle of the night to deliver a baby or stay up admitting and managing a complex patient to an ICU requirng ventilator management and pressors.  The inconvenience to lifestyle is a factor that is also causing OB-GYN’s to give up obstetrics as part of their practice and only focus on office and operative gynecology while laborists manage the burden of hospital obstetrics.  The same for pediatricians and internists who have stopped admitting their own patients to the hospital and allowed hospitalists or nocturnists to manage this time-consuming aspect of care.  The era of HMO’s in the early 90’s allowed Family Doctors the role of gate-keeper, which proved to be lucrative and offered a high income for many Family Physicians without the burden of long hours and having to practice in various areas of the hospital and clinic.  These physicians then stayed comfortable in this role well past the era of the gate-keepers into the present.

That being said, there is a recent and strong resurgence of interest in training in a procedural and broad-scope practice of Family Medicine.  This charge has been led by forward- thinking residency programs like Wesley Family Medicine (my training program), Ventura County Medical Center, the Contra Costa Family Medicine Residency, Via Christi, and several other programs.  Residents in these residencies graduate with a broad range of high-volume, evidence-based procedural and management skills to offer the care intended to be provided by a Family Doctor.  

I don’t believe that just because somebody is a Family Doctor they should be allowed to work in any setting or perform whatever procedure they desire.  They should be extremely well trained and meet the exact same requirements that specialists working in those areas or performing those procedures must meet.   I believe Family Medicine residencies should be extended to at least 4 years of training, especially in the face of recent work hour changes imposed by the ACGME.  

There are some aspects of the Affordable Care Act that are leveling the finanical incentives for those deciding to enter primary care training out of medical school versus more lucrative specialty training, but they are certainly not enough to convince medical students to make this decision at this time.

While I am extremely grateful for and impressed by the role many of my Nurse Practitioner colleagues play, in answer to your question, I don’t believe that they are capable of filling the gap that the true practice of well-trained Family Physicians offer to communities.  I think a solution to our regional physician shortages should be focused on both aggressive student loan forgiveness and high financial incentives for medical students who both enter Family Medicine as a specialty and relocate to rural areas in need of comprehensive health care coverage.  Then emphasis should be placed on physician retention to these areas so there doesn’t need to be turnover every 1 to 4 years once loan forgiveness ends.  High job satisfaction and good pay are the ultimate recruitment tools.  There are currently plans like this in place by the National Health Service Corps, and the Indian Health Services, but I don’t believe they go far enough and are too difficult to obtain for students deciding to pursue Family Medicine. 

I also believe there should be programs in place that help fast-track excellent Nurse Practitioners who have been in practice for several years through medical school and into Family Medicine residencies that will mitigate the costs of further training and shorten their total time in school as some of the training will be redundant to them (for instance some of the basic sciences of the first and second years, but not all of that course work).  I have a brilliant colleague who is a Nurse Practitioner who wants to move beyond the limitations of his clinical training towards becoming a phyician, but it is unfair that he should need to take on another 150 to 300 thousand dollars of debt and 7 more years of training.

​

Travelling To versus Travelling Through

When I first arrived in Chinle I had all of these plans of how I was going to order up some coffee from New Harvest in Rhode Island and use my hand grinder to start brewing brilliant cups of coffee in my hotel room.   Part of this was because I love coffee, part was because I felt obligated to do so since I wrote the book on having good food and coffee in small spaces, and part was because I was being a touch snooty and indulging every single one of my personal preferences.

I had a few pounds of my favorite coffee in the online cart and was about to hit 'purchase' when I had a thought: why on Earth would I travel to all of these places only to drag my preferences along with me?  Why move to an area if I was just going to bring my safe bubble of personal culture with me?  So instead I went to the (only) grocery store in town and found whatever coffee there was to buy.  There was Folgers and the usual stuff, but eventually I found a beautiful bottle of Cafe Combate instant coffee.  And it was as terrible as it sounds.

Instead of having my perfect cup of Cafe Merika every morning (and trust me, I would love it), I had a steaming cup of acrid Cafe Combate, and it became part of my daily routine for 8 weeks, taking the time to find an optimal water to freeze-dried crystal ratio to mute the aftertaste.  And now I have a story for myself about this horrible instant coffee that is made in Mexico City (out of what, I'm not sure) that I eventually came to love.  The taste of that coffee flavors all of my memories there.  If and when I ever have Cafe Combate again, in my mind I'll be instantly transported back to that first trip to Chinle, just like the smells and flavors of travelling abroad to Asia, Europe, Haiti, or Africa do the same.  

The upshot is I think it is one thing if you bring food with you when you travel because you have specific allergies or dietary restriticions, or you don't want to eat pizza every day and gain 60 pounds and get diabetes.  But when it comes to the little things that go along with travel ask yourself if you are traveling to a place versus through a place.  I doubt many people in Chinle drink Cafe Combate besides me, but if I was only drinking coffee from home, and reading the same books, and listening to the same music- then why go to a town in the first place?  You might as well stay home.  

Travel to the destination, not through it.

​

*As a side note, the author in no way advocates drinking horrible coffee for the sake of drinking horrible coffee.  Whenever possible drink great local coffee and brew responsibly!  ​

**Yes, it means 'combat coffee'.  It is in fact, that awesome.  ​

​

386606971767.jpeg

Car smells like good coffee and green chiles and sun is coming up over the mountains. Life is wildly good.

​

Sad Like Leaving Kansas

This morning I'm drinking coffee, enjoying a beautiful Spring morning in the desert with the breeze blowing in through the window.​  In a few minutes I'll start packing up the car and I'll be moving out of my cozy little Navajo Best Western.

I'm really quite sad to be leaving Chinle.  Sad like I was when I left Kansas.  

This was my first Indian Health Services(IHS) assignment.  When you hear people discuss working for IHS they talk about how depressing the experience can be.  I don't know where those people worked, but I have no idea what they were talking about.  Working at the Navajo hospital here has been one of the most joyful experiences of my career. Chinle Hospital has attracted physicians of incredible quality and talent from around the country.  The hospital and clinic staff are approximately 99% Navajo and there is incredible investment into the community as a whole, and the patients are some of the most delightful people I've ever worked for.  

Chinle is what you would expect for a rural high-desert community.  It's a one-horse town (it's actually a seven horse town- those jerk horses run the place wandering through the streets wherever they want) but it lacks nothing in charm or sophistication.  There are only three restaurants, but there is always something to do, from potlucks to  yoga, trail running to ultimate frisbee.  There's even the random dance party in IHS housing from time to time.  And if you look in any single direction you'll see some of the most beautiful and sacred scenery you've ever seen in your life.  

So I'm heading out to Albuquerque for the night to visit with a friend, get the desert sand vacuumed out of the car, eat at the Frontier, and use some normal-speed internet. After those simple luxuries, it's up to another Navajo hospital in Shiprock, New Mexico for a few weeks and then off to China.​

If you're a physician or nurse who has considered IHS but has been scared off by people's perceptions or comments, I highly recommend you rotate through some facilities as a contractor and get a feel for the system.  I think you'll be pleasantly surprised at the opportunity to work with great colleagues and a wonderful patient population. 

​As for me, I'll be back for sure.  I just have the curse of wanderlust to deal with first. 

​

Three Things I Love March 29, 2013

Three Things I Love is a working exercise in gratitude.   Each week I want to reflect on  three things I am currently in love with.  Small things like gear, a service, a good batch of beer, a computer application, a person, or a movement.  You get the idea.  Focus on gratitude.

1. Dr Zahra Shah

          ​​Zahra Shah, MD

          ​​Zahra Shah, MD

Zahra is a residency classmate, a friend, and a great clinician.  Currently she works as a hospitalist in Wichita, KS.

 She surprised me a few weeks ago when asking about medical relief work.  When we got down to the root of it, Zahra wanted to help out with the crisis in Syria because she couldn't stand seeing the violence on the news or the idea of the burden on and loss of doctors in Syria.  So within several weeks she had tied in to an American organization providing medical relief in Syria.  

Zahra has just arrived in Istanbul to train Turkish and Syrian physicians in trauma management (Advanced Trauma Life Support) and then to travel to care for victims of the violence.

We'll be hoping to post updates of Zahra's work  on HeartHandsEyes.com in the coming week.​

​

​

​

​

2.  Sea to Summit Light Line Travel Clothesline

You can't bring it all with you!

One of the easy secrets to packing lite is that you need to pick a simple small wardrobe that is versatile, and you need to be ready to wash it where you can- either at a friend's washer, a laundromat or more likely in a sink or bathtub.  People think it is crazy that I do this, but if the women in Haiti can get their shirts as bright white as they are when they see me from washing in a puddle, I can do it with clean water in the sink in a hotel in Arizona or New Mexico.

Since I am on extended assignments and am a doctor I need to bring just a few more items of clothing than when I travel for pleasure.  That means when I finally get around to doing laundry I have about4-9 items to wash and dry at one time.  

I had for a long time considered the Rick Steves travel clothesline but considered it a luxury and never ordered one.  Now a travel clothesline was becoming a necessity.  I added the line to my cart but then saw the Sea To Summit line advertised at the bottom of my screen and did some research.  I watched a video review comparing the two and decided this was a a better choice for me since it had a more intuitive anchoring system and was longer which would accommodate the types of hotel rooms I usually stay in.

The nylon line (vs braided rubber) is really easy to set up anywhere in my room, and has beaded pinch points that you can use as "clothespins".  The double line also makes it easy to hang pants or towels flat and not let them slide off.  The line also has a good built in cinch to tighten it straight.

I was worried the neoprene pouch would add bulk and weight but it does not and is super helpful in keeping the line in place.

It's a great piece of gear that keeps me able to keep my clothes clean and wrinkle free.  You can easily make one yourself from paracord, but this just is a nice convenient option for 7 to 10 dollars.

3.  Samsara app (iPhone)

 ​

​I think everybody my age wants to or needs to improve their mindfulness, reduce their stress or introduce some kind of meditation practice into their lives.

Several months ago I got really focused on establishing a meditation practice.  I used to just guess at the time when I would sit but the Samsara app has helped me not only keep track of the meditation but also to extend my sitting time over time.

The free  app is really well designed, has a simple layout, a just does what it is supposed to do.

 You set what you need to in regards to time and chime-  both the sound of the bell (it includes one bell chime and you can pay a dollar as an in app purchase to have more but the included chime is just fine), and how many times the opening and closing bells chime.

 I really love this app and it has helped me to increase my sitting time in the morning and evening and has wormed itself to the second screen (and I have contemplated going for the home screen) of my iPhone.

 I have found my meditation practice to be one of the best habits I have introduced into my life and in 2 months I have not gone a day without meditating.  I definitely notice a difference in my stress levels, concentration, and overall well being.